Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.

COVID-19 infection and maternal morbidity in critical care units in Scotland: a national cohort study

BACKGROUND

Previous research has shown that, in comparison with non-pregnant women of reproductive age, pregnant women with COVID-19 are more likely to be admitted to critical care, receive invasive ventilation, and die. At present there are limited data in relation to outcomes and healthcare utilisation following hospital discharge of pregnant and recently pregnant women admitted to critical care.

METHODS

A national cohort study of pregnant and recently pregnant women who were admitted to critical care in Scotland with confirmed or suspected COVID-19. We examined hospital outcomes as well as hospital re-admission rates.

RESULTS

Between March 2020 and March 2022, 75 pregnant or recently pregnant women with laboratory-confirmed COVID-19 were admitted to 24 Intensive Care Units across Scotland. Almost two thirds (n=49, 65%) were from the most deprived socio-economic areas. Complete 90-day acute hospital re-admission data were available for 74 (99%) patients. Nine (12%) women required an emergency non-obstetric hospital re-admission within 90 days. Less than 5% of the cohort had received any form of vaccination.

CONCLUSIONS

This national cohort study has demonstrated that pregnant or recently pregnant women admitted to critical care with COVID-19 were more likely to reside in areas of socio-economic deprivation, and fewer than 5% of the cohort had received any form of vaccination. More targeted public health campaigning across the socio-economic gradient is urgently required.

Critical care provision after colorectal cancer surgery

BACKGROUND

Colorectal cancer (CRC) is the 2nd largest cause of cancer related mortality in the UK with 40 000 new patients being diagnosed each year. Complications of CRC surgery can occur in the perioperative period that leads to the requirement of organ support. The aim of this study was to identify pre-operative risk factors that increased the likelihood of this occurring.

METHODS

This is a retrospective observational study of all 6441 patients who underwent colorectal cancer surgery within the West of Scotland Region between 2005 and 2011. Logistic regression was employed to determine factors associated with receiving postoperative organ support.

RESULTS

A total of 610 (9 %) patients received organ support. Multivariate analysis identified age ≥65, male gender, emergency surgery, social deprivation, heart failure and type II diabetes as being independently associated with organ support postoperatively. After adjusting for demographic and clinical factors, patients with metastatic disease appeared less likely to receive organ support (p = 0.012).

CONCLUSIONS

Nearly one in ten patients undergoing CRC surgery receive organ support in the post operative period. We identified several risk factors which increase the likelihood of receiving organ support post operatively. This is relevant when consenting patients about the risks of CRC surgery.